Upper lateral lip flap for the coverage of large superficial labial defect.

BACKGROUND: Reconstruction of large superficial defects of the upper lip is challenging, as it requires the restoration of both function and morphology. To achieve optimal results, facial features and landmarks should be preserved and similar skin should be used. Moreover, in male patients, upper lip pilosity should be restored. Although myriad of local flaps have previously been described, few address these issues. Herein, we describe our results with an upper lateral lip rotation flap for large upper lip cutaneous defects coverage. PATIENTS AND METHOD: A retrospective study was performed including every patient who underwent an upper lateral lip flap between 2010 and 2017. Demographic data, defect dimensions, etiology, type of anesthesia, operative time, postoperative complications, functional and morphological outcomes were recorded. RESULTS: A total of 31 patients were included. All procedures were performed under local anesthesia as outpatient procedures. The length of the operative procedure was 48minutes in average. The mean size of the superficial defect was 19mm (ranging from 6 to 30mm). All patients were fully healed after 15 days, and no flap necrosis (partial or total) was reported. No nasal or lip distortion was observed and facial hair was successfully restored in all male patients. CONCLUSION: The upper lateral lip flap is a fast, safe, and reproducible procedure to cover defects of the lateral upper lip of up to 3cm. With scars hidden in natural folds and lip defects covered by lip tissues, this technique restores facial cosmetic features with very satisfying aesthetic outcome, especially in men as facial hair is restored.

Is brachioplasty acceptable as an outpatient procedure? A prospective study comparing ambulatory and traditional hospitalization procedures.

BACKGROUND: Ambulatory or outpatient surgery is defined as surgery that does not require an overnight hospital stay. It offers patients both convenience and reduced costs. With the increased use of bariatric surgery, Extended L-shaped Lipo-brachioplasty is now frequently requested as a follow-up procedure. Although numerous studies have focused on its technique and outcomes, none have evaluated its acceptability as an outpatient procedure. This was the aim of this prospective study. PATIENTS AND METHODS: This study was performed between January 2016 and September 2019. All patients undergoing extended L-shaped Lipo-brachioplasty during that period were included and divided into two groups, according to the type of hospitalization. For both groups, we recorded the demographics, medical and surgical data, as well as any postoperative complications. In the outpatient group, we also recorded discharge failures at day 0. RESULTS: 75 patients were included in the study (40 outpatients, 35 hospitalizations). There were no significant differences between the two groups in terms of demographics, surgical data, or the incidence of complications. In the outpatient group, three patients could not be discharged the evening of the procedure and had to stay overnight. No readmissions or major complications were reported in this group. CONCLUSION: Our prospective study shows that outpatient Extended L-shaped Lipo-brachioplasty safely provides the same outcomes as those performed during traditional hospitalization. We believe that for eligible patients, it should routinely be performed as an outpatient procedure.

Determinants of the interindividual variability in serum cytidine deaminase activity of patients with solid tumours.

AIMS: Cytidine deaminase (CDA) activity in cancer patients' serum has been proposed as a predictive biomarker for efficacy and toxicity of nucleoside analogues. However, discrepant results about its predictive value have been reported due to the high interindividual variability in CDA activity. This study aimed at identifying determinants of this interindividual variability. METHODS: From December 2014 to November 2015, 183 patients were prospectively included. Serum CDA activity, biological and clinical characteristics as well as five common single nucleotide polymorphisms (SNPs) in the CDA gene (c.-451C > T, c.-92A > G, c.-33_-31delC, c.79A > C, c.435 T > C) were analysed. Associations between clinical characteristics, pharmacogenetic variants and CDA activity were univariately tested. P < 0.1-candidate variables were analysed through a multivariate analysis. The association between CDA activity and toxicity was assessed for the 56 gemcitabine-treated patients. Intraindividual variability in CDA activity was explored in six pancreatic cancer patients treated with gemcitabine. RESULTS: Median CDA activity was 3.97 U mg-1 (range 1.53-15.49 U mg-1 ). A univariate analysis showed that CDA activity was statistically associated with Eastern Cooperative Oncology Group performance status, mild or severe malnutrition, inflammatory syndrome, leucocyte count, neutrophil count, albumin, C-reactive protein and -c.-33_-31delC single nucleotide polymorphism. A multivariate analysis identified that only neutrophil count (P < 0.0001) and severe malnutrition (P = 0.0278) were independently associated with CDA activity. Low CDA activity (<2 U mg-1 ) was not statistically associated with severe gemcitabine-related toxicities (P = 0.16). A decrease in CDA activity was observed during the longitudinal follow-up of six pancreatic cancer patients treated with gemcitabine (P = 0.03). CONCLUSIONS: These results suggest that neutrophil count and malnutrition should be considered for the interpretation of pretherapeutic CDA activity.

Study of medical education in 3D surgical modeling by surgeons with free open-source software: Example of mandibular reconstruction with fibula free flap and creation of its surgical guides.

INTRODUCTION: Benefits of 3D printing techniques, biomodeling and surgical guides are well known in surgery, especially when the same surgeon who performed the surgery participated in the virtual surgical planning. Our objective was to evaluate the transfer of know how of a neutral 3D surgical modeling free open-source software protocol to surgeons with different surgical specialities. METHODS: A one-day training session was organised in 3D surgical modeling applied to one mandibular reconstruction case with fibula free flap and creation of its surgical guides. Surgeon satisfaction was analysed before and after the training. RESULTS: Of 22 surgeons, 59% assessed the training as excellent or very good and 68% considered changing their daily surgical routine and would try to apply our open-source software protocol in their department after a single training day. The mean capacity in using the software improved from 4.13 on 10 before to 6.59 on 10 after training for OsiriX® software, from 1.14 before to 5.05 after training for Meshlab®, from 0.45 before to 4.91 after training for Netfabb® and from 1.05 before and 4.41 after training for Blender®. According to surgeons, using the software Blender® became harder as the day went on. DISCUSSION: Despite improvement in the capacity in using software for all participants, more than a single training day is needed for the transfer of know how on 3D modeling with open-source software. Although the know-how transfer, overall satisfaction, actual learning outcomes and relevance of this training were appropriated, a longer training including different topics will be needed to improve training quality.

Should we consider the hemi-tip as a proper aesthetic subunit in a nasal reconstruction?

BACKGROUND: Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU. MATERIAL AND METHODS: We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved <50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters. RESULTS: From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5. DISCUSSION: Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction. CONCLUSION: We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

Three-dimensional surgical modelling with an open-source software protocol: study of precision and reproducibility in mandibular reconstruction with the fibula free flap.

Very few surgical teams currently use totally independent and free solutions to perform three-dimensional (3D) surgical modelling for osseous free flaps in reconstructive surgery. This study assessed the precision and technical reproducibility of a 3D surgical modelling protocol using free open-source software in mandibular reconstruction with fibula free flaps and surgical guides. Precision was assessed through comparisons of the 3D surgical guide to the sterilized 3D-printed guide, determining accuracy to the millimetre level. Reproducibility was assessed in three surgical cases by volumetric comparison to the millimetre level. For the 3D surgical modelling, a difference of less than 0.1mm was observed. Almost no deformations (<0.2mm) were observed post-autoclave sterilization of the 3D-printed surgical guides. In the three surgical cases, the average precision of fibula free flap modelling was between 0.1mm and 0.4mm, and the average precision of the complete reconstructed mandible was less than 1mm. The open-source software protocol demonstrated high accuracy without complications. However, the precision of the surgical case depends on the surgeon's 3D surgical modelling. Therefore, surgeons need training on the use of this protocol before applying it to surgical cases; this constitutes a limitation. Further studies should address the transfer of expertise.

Use of the 3D surgical modelling technique with open-source software for mandibular fibula free flap reconstruction and its surgical guides.

INTRODUCTION: Tridimensional (3D) surgical modelling is a necessary step to create 3D-printed surgical tools, and expensive professional software is generally needed. Open-source software are functional, reliable, updated, may be downloaded for free and used to produce 3D models. Few surgical teams have used free solutions for mastering 3D surgical modelling for reconstructive surgery with osseous free flaps. We described an Open-source software 3D surgical modelling protocol to perform a fast and nearly free mandibular reconstruction with microvascular fibula free flap and its surgical guides, with no need for engineering support. PROCEDURE: Four successive specialised Open-source software were used to perform our 3D modelling: OsiriX®, Meshlab®, Netfabb® and Blender®. Digital Imaging and Communications in Medicine (DICOM) data on patient skull and fibula, obtained with a computerised tomography (CT) scan, were needed. The 3D modelling of the reconstructed mandible and its surgical guides were created. CONCLUSIONS: This new strategy may improve surgical management in Oral and Craniomaxillofacial surgery. Further clinical studies are needed to demonstrate the feasibility, reproducibility, transfer of know how and benefits of this technique.

[Setting of a breast autologous microsurgical reconstructive surgery evolution in 20 years and review of 1138 cases]. / Mise en place d'une activité de reconstruction microchirurgicale du sein par tissus autologues. Évolution sur 20 ans et revue de 1138 cas.

UNLABELLED: The authors conducted a retrospective study of breast reconstruction with DIEP free flap between 1994 and 2014 by a single team. MATERIAL AND METHOD: A retrospective analysis of all operative charts and hospitalization was conducted for the period from 1994 to 2014. The number of cases per year, the complication rate of the donor site and recipient site, and surgery time were recorded. Sequence analysis was conducted to determine the elements that have enabled to implement this technique reliably and effects of the learning curve. The series was split into two periods (1994/2011 and 2012/2014) corresponding to two different hospitals with the same team. RESULTS: The total number of shreds of 1138 between November 1994 and December 2014 respectively with 477 and 661 the period 1994/2011 to 2012/2014 period. The failure rate increased from 8% to 2.2%. CONCLUSION: The establishment of units mainly dedicated to microsurgical reconstruction can offer the DIEP technique reliably and reproducibly.

[Horizontal V-Y advancement flap for lower eyelid reconstruction in young patients]. / Le lambeau d'avancement horizontal en V-Y dans les reconstructions des pertes de substances non transfixiantes de la paupière inférieure chez le sujet jeune.

PURPOSE: The reconstruction of lower eyelid defects is a complex issue because of the thinness of eyelid tissues and the need for protection of the globe. The surgery must address two requirements: a functional goal, avoiding eyelid malposition, and a cosmetic goal, limiting aesthetic compromises. In young patients, direct closure is rarely possible if the defect is superior to 1cm. The horizontal V-Y advancement flap is a simple and reliable method but is hardly ever reported. The purpose of this study is to review the surgical technique and report our experience with this flap in the reconstruction of younger patients. PATIENTS AND METHODS: Nine patients, 5 men and 4 women, with a mean age of 54 years, underwent a lower eyelid reconstruction by horizontal V-Y advancement flap between 2011 and 2014. In every case, the initial pathology was a basal cell carcinoma and the surgical margins were uninvolved. The mean diameter of the surgical defect was 1.9 centimeters and the average procedure duration was 40 minutes. RESULTS: All patients were managed as outpatients. Functional and aesthetic results were judged satisfactory or very satisfactory by all the patients and their surgeon. No flap necrosis and no ectropion or scleral show were reported. In one patient, lower lid edema lasted until the third postoperative month. CONCLUSION: The horizontal V-Y advancement flap enables to repair lower eyelid defects using nearby skin of similar characteristics. Aesthetic results are very satisfactory, and scars, concealed in the eyelid creases, are nearly invisible in the long term. The lack of tension on the eyelid margin limits the risk of eyelid position. This simple and reliable one-step procedure, possible under local anesthesia, is appropriate for young, active patients, limiting the cosmetic sequelae and social ramifications.

[Morphological evaluation of genioplasty associated with orthognathic surgery]. / Évaluation morphologique des génioplasties associées à la chirurgie orthognathique.

INTRODUCTION: The maxillo-mandibulary dysphormias are frequently associated with morphological abnormalities of the chin. Their correction in the sagittal and transverse planes can benefit both morphologically and functionally. The purpose of this study was to evaluate the morphological benefit of the osseous genioplasty associated with orthognathic surgery depending on the type of technique used, as well as complications occurred. PATIENTS AND METHODS: We identified patients who underwent osseous genioplasty associated with orthognathic surgery in our department between 2004 and 2010. For each patient Angle class, type of osteotomy, genioplasty and postoperative complications were recorded. The morphological results were evaluated by a group of surgeons and a group of observers using standardized photographs. RESULTS: Of the 203 facial osteotomies performed during this period, 101 osseous genioplasties were made. In most cases, there was a height reduction associated with advancement of the chin. The morphological results were considered as satisfactory all evaluators alike (3.92). The best results were obtained in height reductions with advancement techniques as sliding genioplasty (4.03) and jumping divided genioplasty (4.19). Five patients (5.9%) had a postoperative complication. This was especially one mental nerve injury and two dental mortifications. No default of consolidation or necrosis or hematoma of mouth floor have been reported. CONCLUSION: Osseous genioplasty is a safe, reliable procedure with morphological satisfactory outcome, in combination with orthognathic surgery. The best results were obtained with cases of height reduction with advancement of the chin, especially the original technique of the jumping divided genioplasty.

[Clitoridal reconstruction after female circumcision]. / Chirurgie réparatrice du clitoris après excision rituelle.

Ritual sexual mutilations affect 140million of women around the world with over three millions new cases per year. France is not spared with 55,000 mutilated women living on our territory. There is a simple, reliable and reproductible reconstructive surgical technique described by the French urologist Pierre Foldès. This technique is still unknown by patients and plastic surgeons. Through a clinical case, the authors discuss the principles, results and key points of this procedure.

[Breast reconstruction with superior gluteal artery perforator (SGAP) flap without intraoperative setup change. About eight cases]. / Reconstruction mammaire par lambeau de superior gluteal artery perforator (SGAP) sans changement d'installation. À propos de huit cas.

INTRODUCTION: The superior gluteal artery perforator flap (SGAP) typically requires a peroperative change of the patient's position that increase the duration time of the procedure and the hospitalization. The aim of this study is to present our serie of eight consecutive SGAP flaps without setup change, and to precise the surgical technique we used. PATIENTS AND METHODS: This is a retrospective series of eight consecutive SGAP flaps performed between September 2001 and March 2010. All these flaps were performed without peroperative setup change. We studied the number of perforators used and their origins, the type of recipient vessels, the duration time of the procedure and the hospitalization. We also analyzed the morphological and functional outcomes for the donor site. RESULTS: All eight flaps were raised on a single septo-cutaneous perforator located between the gluteus maximus and gluteus medius muscles. The internal mammary vessels were chosen as recipients in all cases. The average duration time of the operation was 6 hours and 5 minutes. We report one flap loss. No functional or morphological complications were reported on the donor site. The morphological results on the reconstructed breast were satisfactory or very satisfactory in most cases. CONCLUSION: A satisfying breast reconstruction can be achieved with the SGAP flap without changing setup. The use of the septo-cutaneous branch between the gluteus maximus and gluteus medius muscles lengthens the pedicle and reduces the surgery time by facilitating the dissection. SGAP is therefore another autologous technique for breast reconstruction with low morbidity, when a DIEP flap cannot be harvested.

[Increasing the reliability of SIEA flap using peroperative fluorescent angiography with indocyanine green in breast reconstruction]. / Fiabilisation du lambeau de SIEA par angiographie fluorescente peropératoire au vert d'indocyanine en reconstruction mammaire.

UNLABELLED: The lower abdominal skin and fat have become a standard for breast reconstruction. For 30 years, techniques have evolved, seeking to reduce the morbidity while increasing the reliability of the flap. The Superficial Inferior Epigastric flap Artery (SIEA) spares the abdominal fascia and provides a very satisfying autologous breast reconstruction. However, the pedicle of this flap and its angiosome exhibit a considerable variability, making its use less reliable than other abdominal flaps. MATERIAL: The Indocyanine green (ICG) is soluble dye. When illuminated by an near-infrared light, the ICG emits fluorescence that is not trapped by the skin. A single device (Photo Dynamic Eye(®)) provides the emission of the near-infrared light and the reception of the fluorescence. It provides therefore a simple and efficient intraoperative real-time surface angiographic imaging. SURGICAL PROTOCOL: After dissecting the superficial inferior epigastric vessels, the abdominal flap was harvested from the abdominal wall preserving one perforator arising from the deep inferior epigastric vessels. The perforator was then clamped, and the vascular territory of the SEIA artery was visualized using laser-induced fluorescence of the indocyanine green. The surgical technique was modified depending on the indication for surgery and the result of perfusion measurements. RESULTS: The authors present four clinical cases of breast reconstruction with SIEA to illustrate this procedure. CONCLUSION: The SIEA flap is another surgical technique to achieve autologous breast reconstruction without abdominal morbidity or muscular dissection. Intraoperative angiographic imaging with ICG makes this flap more reliable.

[Current role of laparoscopy in the diagnosis and treatment of ovarian cysts]. / Place actuelle de la coelioscopie dans le diagnostic et le traitement des kystes ovariens.

Between October 1986 and March 1990, 220 patients underwent surgical treatment for ovarian cysts. 156 of these patients underwent an initial celioscopy and could potentially benefit from celiosciopic treatment. The group mean age was 33.3 years. The circumstances under which the cysts were discovered usually consisted of pelvic pain or diagnosis during a routine examination. Twenty-four patients underwent laparotomy immediately after coelioscopy either due to a suspect macroscopic diagnosis either due to technical difficulties. 84.6 percent of the patients in the group were able to undergo celioscopic treatment only, essentially consisting of intraperitoneal cystectomy. The main advantages were the reduction in adherent sequelae in these women of a sexually active age, but also some financial savings related to the reduced duration of hospitalization and of sick leave. The theoretical reservations consist of the risk of malignancy and macroscopic diagnosis following coelioscopic exploration must be very restricted, with laparotomy whenever there is any doubt. No malignant tumor was escaped detection in this group.

[Sites of endometriosis]. / Localisations de l'endométriose.

Endometrious may be located in many parts of the body which are not limited to the pelvic region. While the classical theory of menstrual reflux easily accounts for the genital locations, other theories, notably metaplasia, have been propounded to explain more remote locations. Among the sites of implantation of the disease, the most common is the ovary followed, in order of frequency, by the anterior and posterior parts of the vaginal fornix, the broad ligament of the uterus and the uterosacral ligaments. Endometriosis of the digestive or urinary tract may create problems of differential diagnosis with cancer. External locations are much less frequent.